Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
How would you approach a patient with metastatic alveolar rhabdomyosarcoma with progression on first-line therapy?
Progression while on therapy in the setting of initially metastatic rhabdomyosarcoma is a very unfortunate situation for which I would not consider there to be curative options. The first consideration I would give in this setting is to assess if there are any available clinical trials. If no clinic...
What is the typical time course of cytopenias after CAR-T therapy, and how do you treat them?
There are no specific guidelines but most patients will have some degree of count recovery week 4-6 but albeit not always the strongest recovery.Management of neutropenia varies widely from institution to institution with regards to utilization of GCSF. Some places will start it in a prophylactic ma...
How young is too young to treat a child's keloid with radiation?
I think this is a helpful question and I think the following questions appropriately highlight the considerations. We do not routinely see or manage these at our center, so I welcome comments from the invited respondents.This is a controversial area and I think there are certainly exceptions which s...
Is there experience/reports of using voxelotor in sickle cell patients who are Jehovah Witnesses with few crises but who have fatigue and/or dyspnea?
I would not hesitate to use voxelotor in most patients with sickle cell anemia, including Jehovah's Witnesses, if they have not responded to hydroxyurea with near cessation of acute vasoocclusive events and have continued hemolytic anemia. Voxelotor usually reduces hemolysis that results in an incre...
What is your preferred approach for patients with anti-phospholipid syndrome with recurrent thrombosis on coumadin and LMWH?
This is a difficult condition to manage and personalized approach/risk stratification is key. There are several potential considerations:Warfarin therapy could be intensified, anti-platelet agents could be considered (although not in combination with LMWH).For patients with an underlying autoimmune ...
When do you offer adjuvant radiation therapy for high grade non-rhabdomyosarcoma soft tissue sarcoma (NRSTS) in a skeletally mature teenager or young adult?
ARST0332 tested whether a risk stratification system based on clinical prognostic factors would separate young patients with non-rhabdo STS into different prognostic subgroups and whether each factor used for allocation would be a strong predictor of outcome. A combination of factors was used to ass...
What is your approach to adjuvant treatment for stage IA small cell carcinoma of the ovary, hypercalcemic type, after fertility sparing surgical staging?
Due to the rarity of small cell carcinoma of the ovary hypercalcemic type (SCCOHT), limited prospective data exists to inform treatment decisions. Like other malignancies in the malignant rhabdoid tumor (MRT) family including renal and extra-renal MRT and atypical teratoid rhabdoid tumors (ATRT), SC...
When would you consider stopping chronic transfusion therapy in a sickle cell patient with history of abnormal TCDs but no stroke?
Fortunately, we have good data to answer this question. The TWiTCH trial aimed to determine the efficacy of hydroxyurea at maintaining TCD velocities after discontinuation of initial transfusion therapy to prevent primary stroke. Patients on this non-inferiority trial with a history of abnormal TCD ...
What guidance do you give to patients and families regarding resuming vaccination after completion of chemotherapy?
In our practice, for vaccine series that have not been started or only a single prior dose has been administered, we recommend a new vaccine series according to the CDC regular or catch up schedule. For vaccine series that have been started with at least 2 prior doses, or completed, we recommend a s...
In patients who develop a VTE, what conditions do you consider as persistent, provoking risk factors, and at what point are they controlled enough to stop anticoagulation?
Not a lot of controlled trials that address each situation so we rely on expert consensus and judgement, and more importantly, balancing the risk of hemorrhage vs thrombosis. ASH guidelines define chronic persistent risk factors as 1) Active cancer (e.g., ongoing chemotherapy; recurrent or progressi...